Dr. Sridharan

Natalie Sridharan, MD, UPMC Vascular Surgeon explains what causes varicose veins, the treatments available and why they may be more than just a cosmetic concern.

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This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider. Varicose veins: what causes them, how can you treat them, and why they are more than just a cosmetic concern. Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat podcast, and joining us right now is UPMC vascular surgeon, Dr. Natalie Sridharan. Thank you so much for coming in and spending time with us today.

– Thank you for having me.

– OK. Let’s begin really with what’s the difference between varicose veins and spider veins?

– Yeah, so varicose veins are those more large, bulging veins that people see on their legs. Whereas spider veins tend to be smaller, blue-colored, very small, not bulging veins that people tend to be bothered by more cosmetically. However, even spider veins can be present in patients with underlying venous insufficiency.

– And so, what do we know about what causes varicose veins?

– So, a lot of people have venous insufficiency or varicose veins, and not all of these patients are going to have a clear reason why they develop this. Some of it’s luck of the draw, but there certainly are things that put patients at higher risk of developing varicose veins or venous insufficiency. Women are more likely, as we age, as we gain weight, pregnancies, which certainly put women at increased risk. Patients with a history of a DVT or a blood clot can be at increased risk of having venous insufficiency. And patients with a family history; there’s a strong genetic component to varicose veins.

– What about occupations where you stand on your feet for a very long time? Are those types of folks more susceptible?

– Yeah, I definitely see a lot of patients who have jobs where they’ve — a lot of nursing, a lot of people who work in restaurants, things like that — where they spend a lot of time on their feet and definitely at a higher risk. I see a lot of nurses who have been wearing compression stockings all their lives to try to prevent that, but still often can benefit from seeing a vascular surgeon and further treatments.

– And so, what actually happens in the body to the veins? How do they end up bulging, and getting to that degree?

– Right. So, the veins’ job is to bring blood back to the heart from all of the extremities. In the legs, in particular, they have to work against gravity to do that. And so, as they take blood back to the heart, they have within them a mechanism, and that mechanism, there’s valves. They’re supposed to be one-way valves. So, as the blood travels past the valve on its way back to the heart, it’s not supposed to be able to go back down, but for a variety of reasons that we already discussed — such as weight gain, and age, and genetics — those valves can become leaky. And so the blood goes up, but it also goes back down, and that downward pressure is what causes blood to pool in the extremity. This can lead to swelling, bulging veins, pain, edema, itching, a whole spectrum of symptoms.

– And so outside of they might be unsightly to look at, what are sort of the medical complications and the concerns that someone should take these seriously?

– Yeah. So, I always tell patients that for the vast majority of patients with venous insufficiency or varicose veins, if they’re going to have a problem, this is a good problem to have. Because for the most part, it’s not terribly dangerous, although it can really affect people’s quality of life. However, there is a very severe spectrum of disease, and we care for those patients as well that can have such severe venous insufficiency or such severe pressure in the leg that they have debilitating swelling, or even to the point that they get venous ulcerations that require special dressings and specialized wound care, which we certainly help take care of. Some patients, also, one complication can be that varicose veins can spontaneously thrombose. Now, this is different than DVT. However, this phenomenon called phlebitis can be very painful. Also, varicose veins are known sometimes to bleed, and that can be very dramatic bleeding and causes a lot of concern.

– And so, when does someone know, if you can just put up with, oh, my legs don’t look that nice, when does someone know it is time to go, and get checked, and get treatment?

– Well, we’re happy to see anyone and help them make that sort of decision, but I think the symptoms really drive seeking medical attention. So, if you have varicose veins or you have swelling in your leg, and you have symptoms like cramping, aching, especially after long periods of time on your feet, or with your legs down, a lot of people describe restless legs or itching. All of those symptoms can be signs of venous insufficiency, and seeing a vascular specialist and getting specialized ultrasound testing can help diagnose if you have underlying venous insufficiency, which is often very treatable.

– And so, let’s talk about some of the treatments first, and then really how you decide and what the approach is when someone comes in for care.

– Yeah. So, like I said, most patients are going to fall in the category where they’re not suffering from things like phlebitis, or bleeding veins, or debilitating swelling or wounds. And so, for those patients, because venous insufficiency is not life- or limb-threatening, we do start with conservative measures first. Some patients will actually get a great benefit from a number of conservative measures, and those things involve, most importantly, compression stockings, but also the elevation of the leg and exercise. When you walk, the muscles in your legs act a little bit like pumps to help move that blood back towards the heart, and so those are the things that we institute initially in patients that don’t have any of those severe symptoms. And then we follow them up to see if those things have caused an improvement in their symptoms, or whether they warrant additional intervention.

– Can lasers be used for anything more so on the cosmetic end, or how do they play into treatment?

– Yeah. So, there are treatments that involve lasers. Some of them are for spider veins, so just cosmetic, but there is laser used as one of the endovenous ablation techniques. So, for patients who have reflux in a saphenous vein, which is a vein that runs the length of your leg, there’s one on the inside of your leg and one on the outside of the leg, and to know if there’s venous insufficiency or reflux in one of those veins, it requires specialized venous reflux testing, which we do in our clinics. And if there is reflux in one of those veins, we can treat it often with an endovenous catheter-based technique, and that can include endovenous laser ablation, radiofrequency ablation, or mechanical chemical ablation, or MOCA.

– When someone comes to see you, how do you determine where they are on the scale, and then what is appropriate?

– Right. So, like I said, first, we try those conservative things, and we get this venous reflux testing. And what that tells me is whether there is reflux in one of those veins, like a saphenous vein — that’s a long, straight vein and can be treated with a long, straight catheter — or it’s just the bulging superficial varicosities, which, because of their tortuosity, often can’t be treated with a long, straight catheter. Typically, we treat those with a number of different approaches. If they’re small enough, we can treat them with injections of medication, usually a foam medication that we use just in the office under ultrasound that causes the veins to scar in on themselves. This is called sclerotherapy. That’s something a lot of people have heard of. Alternatively, in some patients that have very, very large veins, we do actually do surgical removal of those veins, and that’s called a phlebectomy. We make very small incisions that heal very cosmetically, but actually remove the veins from underneath the skin.

– And then how does the rest of the body function if you’re removing veins?

– Right. I get that question a lot. So, patients ask, what if I need this vein? And I always tell them, it’s a dysfunctional vein. So your body, it’s not one that can be used for something else, like a bypass or something like that, and our body has sort of a limitless number of veins. So, the way we treat superficial venous insufficiency is generally with some sort of ablation, whether that’s sclerotherapy or a catheter-based technique, or whether it’s actual surgical removal of the veins. We essentially get rid of them in some way, and your body, because it has a limitless supply of veins, has other healthy veins to take over and do the function of those dysfunctional veins.

– Is there a certain time of year that’s better than others to treat varicose veins?

– That’s a great question. Particularly for sclerotherapy, the medications that we use can cause some skin staining if exposed to the sun. So, I often see patients in the springtime as they’re starting to think about their summer vacations, and getting their legs ready for some sun exposure, but it’s sort of the wrong time to be doing it. I actually will tell them to try to get through that summer, and come back and see me in the fall for treatments because you do want to avoid sun exposure for about six weeks after sclerotherapy treatments, or you can get some permanent skin staining.

– All right. So, we talked about more prevalent in women, lot to do with pregnancy, weight, etc. So, outside of compression stockings, is there anything else that we can do in a prevention mode? You know, does it matter how we sit, whether we cross our legs, what’s all that look like?

– I get a lot of that question as well, and sometimes when it comes to varicose veins, a little bit, the die is cast. There’s not much we can do, really, to prevent them other than if you are gonna spend a lot of time on your feet, or spend long, long trips, or things like that, to try wearing compression stockings and elevating your legs. But as far as the sort of things that your grandmother may have said about crossing your legs and so on, those things are not known to increase your risk of developing varicose veins.

– So, let me ask, you are so passionate about all of this. What do you love most about your job, and why was this a field of medicine that you decided that you wanted to take part in?

– Vascular surgery is really a broad spectrum. We treat patients with vascular disease, aneurysms, carotids, and on the other side of the spectrum, venous disease, which is the other part of the circulatory system, and I really enjoy taking care of all this breadth of patients. My venous patients often are not as critically ill, and there’s a lot we can do to improve their quality of life, and I find them to be one of the most pleasant patient populations to work with because they get so much improvement in their overall quality of life. You know, their legs don’t ache anymore, they don’t have restless legs at night, and so it’s a very — the days that I deal with venous patients are sort of much more relaxing days. It’s a lot of positivity among treating venous insufficiency. Like I said earlier on, I tell patients this is a good problem to have if you’re going to have a problem. Because not only is it generally not life- or limb-threatening, we have so many good options for treatment, and they’re almost all universally safe and very effective.

– Well, doctor, thank you so much for coming in and spending some time with us today. Some great information. We appreciate your time.

– OK. Thank you so much for having me.

– You’re welcome. I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.

About Heart and Vascular Institute

The UPMC Heart and Vascular Institute has long been a leader in cardiovascular care, with a rich history in clinical research and innovation. As one of the first heart transplant centers in the country and as the developer of one of the first heart-assist devices, UPMC has contributed to advancing the field of cardiovascular medicine. We strive to provide the most advanced, cutting-edge care for our patients, treating both common and complex conditions. We also offer services that seek to improve the health of our communities, including heart screenings, free clinics, and heart health education. Find an expert near you.